Orthopedics

Feature Article 

Risk Factors for and Results of Late or Delayed Amputation Following Combat-related Extremity Injuries

CPT Melvin D. Helgeson, MD; MAJ Benjamin K. Potter, MD; CPT Travis C. Burns, MD; Roman A. Hayda, MD, COL (Ret); LTC Donald A. Gajewski, MD

  • Orthopedics. 2010;33(9)
  • Posted September 1, 2010

Abstract

We studied patients with combat-related injuries that required delayed amputation at least 4 months after the initial injury due to dysfunction, persistent pain, and patient desires. Late amputations were performed 22 times in 22 patients (21 men, 1 woman) since 2003. Fourteen patients underwent transtibial amputation, 5 transfemoral amputations, 1 knee disarticulation, and 2 transradial amputations. The primary indications for late amputation were neurologic dysfunction in 6 patients, persistent or recurrent infection in 6, neurogenic pain in 3, non-neurogenic pain in 5, and a globally poor functional result in 2. Sixteen of 22 patients reported multiple indications for electing to undergo amputation, with an average of 2.1 specific indications per patient. At final clinical follow-up an average of 13 months after amputation, all patients reported subjectively improved function and reported that they would undergo amputation again under similar circumstances.

When medically and functionally practicable, every effort is given to limb salvage following severe combat-related extremity injuries. There is no single risk factor that increases the likelihood of delayed amputation, but the combination of complex pain symptoms with neurologic dysfunction appears to increase the risk, particularly if the initial insult is a severe hindfoot injury or distal tibia fracture. With appropriately selected and counseled patients, elective late amputation results in a high degree of patient satisfaction and subjectively improved function.

Traumatic and early combat-related amputations remain a critical and necessary aspect of battlefield and wartime medicine. The rates of amputation following severe combat-related extremity trauma have generally fallen chronologically across historical US military conflicts due to the progressive advancement of limb salvage capabilities.1,2 However, amputation rates as a percentage of all battle injuries remained relatively consistent throughout the World and Korean Wars (1%-2%)3-5 but nearly doubled during the Vietnam War and the current Operations Iraqi and Enduring Freedom (2%-3%).6,7 The apparent discrepancy amongst these data can be in large part attributed to increased survival of critically injured soldiers due to modern body armor, rapid aeromedical evacuation, forward movement of medical resources, and medical advancements in the face of increasingly severe combat and blast-related wounds.

Nonetheless, when medically and functionally practicable, every effort is given to limb salvage following severe combat-related extremity injuries. The end functional results of complex limb salvage can sometimes be gratifying but are often disappointing.8,9 In some cases, therefore, a salvaged limb may remain painful, stiff, poorly functioning, and cosmetically disfigured at or near the conclusion of surgical treatment and rehabilitation such that patients elect to undergo late amputation. Elective amputation is commonly performed for chronic infection, peripheral vascular disease, and musculoskeletal tumors. However, relatively little is known about the results of and reasons for elective amputation for management of chronic pain or poor limb function, particularly following combat-related or blast injuries. This article assesses the clinical outcomes of and risk factors for late or delayed amputation following traumatic, combat-related extremity injuries.

Following approval by the Institutional Review Boards at both institutions, we performed a retrospective review of the Walter Reed Army Medical Center and Brooke Army Medical Center orthopedic service surgery logs and orthopedic surgery Operations Iraqi and Enduring Freedom tracking databases to identify patients with combat-related extremity injuries that underwent delayed amputation (>4 months from initial injury) due to dysfunction, persistent pain, and/or patient wishes between September 11, 2001, and June 29, 2006. The review population consisted of >2500 inpatients who required orthopedic surgery care for combat-related extremity injuries, including nearly 500 major amputations in >400 patients.

Data concerning possible risk factors for late amputation and/or chronic pain, including zone of injury, mechanism of injury, severity of initial injuries, treatment course, residual joint stiffness and tendon/motor…

Abstract

We studied patients with combat-related injuries that required delayed amputation at least 4 months after the initial injury due to dysfunction, persistent pain, and patient desires. Late amputations were performed 22 times in 22 patients (21 men, 1 woman) since 2003. Fourteen patients underwent transtibial amputation, 5 transfemoral amputations, 1 knee disarticulation, and 2 transradial amputations. The primary indications for late amputation were neurologic dysfunction in 6 patients, persistent or recurrent infection in 6, neurogenic pain in 3, non-neurogenic pain in 5, and a globally poor functional result in 2. Sixteen of 22 patients reported multiple indications for electing to undergo amputation, with an average of 2.1 specific indications per patient. At final clinical follow-up an average of 13 months after amputation, all patients reported subjectively improved function and reported that they would undergo amputation again under similar circumstances.

When medically and functionally practicable, every effort is given to limb salvage following severe combat-related extremity injuries. There is no single risk factor that increases the likelihood of delayed amputation, but the combination of complex pain symptoms with neurologic dysfunction appears to increase the risk, particularly if the initial insult is a severe hindfoot injury or distal tibia fracture. With appropriately selected and counseled patients, elective late amputation results in a high degree of patient satisfaction and subjectively improved function.

Traumatic and early combat-related amputations remain a critical and necessary aspect of battlefield and wartime medicine. The rates of amputation following severe combat-related extremity trauma have generally fallen chronologically across historical US military conflicts due to the progressive advancement of limb salvage capabilities.1,2 However, amputation rates as a percentage of all battle injuries remained relatively consistent throughout the World and Korean Wars (1%-2%)3-5 but nearly doubled during the Vietnam War and the current Operations Iraqi and Enduring Freedom (2%-3%).6,7 The apparent discrepancy amongst these data can be in large part attributed to increased survival of critically injured soldiers due to modern body armor, rapid aeromedical evacuation, forward movement of medical resources, and medical advancements in the face of increasingly severe combat and blast-related wounds.

Nonetheless, when medically and functionally practicable, every effort is given to limb salvage following severe combat-related extremity injuries. The end functional results of complex limb salvage can sometimes be gratifying but are often disappointing.8,9 In some cases, therefore, a salvaged limb may remain painful, stiff, poorly functioning, and cosmetically disfigured at or near the conclusion of surgical treatment and rehabilitation such that patients elect to undergo late amputation. Elective amputation is commonly performed for chronic infection, peripheral vascular disease, and musculoskeletal tumors. However, relatively little is known about the results of and reasons for elective amputation for management of chronic pain or poor limb function, particularly following combat-related or blast injuries. This article assesses the clinical outcomes of and risk factors for late or delayed amputation following traumatic, combat-related extremity injuries.

Materials and Methods

Following approval by the Institutional Review Boards at both institutions, we performed a retrospective review of the Walter Reed Army Medical Center and Brooke Army Medical Center orthopedic service surgery logs and orthopedic surgery Operations Iraqi and Enduring Freedom tracking databases to identify patients with combat-related extremity injuries that underwent delayed amputation (>4 months from initial injury) due to dysfunction, persistent pain, and/or patient wishes between September 11, 2001, and June 29, 2006. The review population consisted of >2500 inpatients who required orthopedic surgery care for combat-related extremity injuries, including nearly 500 major amputations in >400 patients.

Data concerning possible risk factors for late amputation and/or chronic pain, including zone of injury, mechanism of injury, severity of initial injuries, treatment course, residual joint stiffness and tendon/motor deficits, open fractures, chronic infection, and nerve injuries, were collected. Additionally, we assessed the time from initial injury to amputation and subjective patient-reported results following elective amputation. We also reviewed available radiographic imaging and clinical photographs, when available, to further elucidate the severity of the initial injuries on arrival at Walter Reed Army Medical Center or Brooke Army Medical Center, the patients’ subsequent treatment courses and healing processes, and their ultimate cosmetic and apparent functional results prior to elective amputation.

Although conversations with their orthopedic surgeon during follow-up clinical visits may have impacted or biased patient decision making, all patients included in our final data analysis formally requested a delayed amputation. Additionally, we excluded patients who were advised or elected to undergo amputation early during their post-injury convalescence due to unsalvageable injuries, severe local infection, or a high likelihood of profound functional deficits and unsatisfactory final results. Furthermore, the decision to perform an early amputation has frequently already been made by the time the patients arrive at our tertiary care facilities. Thus, limb salvage may be considered to have subjectively failed in these patients, but our series is limited to patients in whom limb salvage was medically feasible and initially successful, and patients with unreconstructable injuries or early amputations were excluded.

Finally, all patients in the present series were mandated to have a second opinion from an orthopedic surgeon, a formal psychiatric evaluation, and arranged meetings with prosthetists and current amputees in rehabilitation prior to their elective amputations, as well as detailed preoperative surgical counseling regarding potential complications of amputation and probable residual functional limitations following prosthetic fitting and rehabilitation.

Table 1: Summary of Delayed Amputations

Results

Twenty-two patients met the inclusion criteria and underwent 22 elective amputations at Walter Reed Army Medical Center or Brooke Army Medical Center >4 months after their initial combat-related injuries during the study period (Table 1). A majority of the injuries were blast-related (n=21), and 1 patient was a pedestrian struck by a vehicle. The patients, 21 men and 1 woman with an average age of 27 years (range, 20-35 years; median, 27 years), were initially treated with limb salvage, with the average number of attempted limb salvage procedures being 11.8 (range, 6-25; median, 10.5). The final limb salvage procedure occurred an average of 103 days after the date of injury (range, 12-792 days; median, 34.5 days). Following extensive multidisciplinary counseling to include orthopedists, physiatrists, therapists, psychiatrists, and peer counselors, 14 patients underwent transtibial amputation, 5 transfemoral amputation, 1 knee disarticulation, and 2 transradial amputations (Figure).

Figure A: A blast injury Figure B: Type IIIB distal femur, patella, and proximal tibia fracture Figure C: Type IIIB distal femur, patella, and proximal tibia fracture Figure D: Limb salvage to include arthrodesis
Figure E: This was complicated by infection Figure F: Biplaner external fixation Figure G: Biplaner external fixation Figure H: Biplaner external fixation
Figure I: Transfemoral amputation Figure: A 28-year-old woman (patient #5) sustained a blast injury (A) resulting in a type IIIB distal femur, patella, and proximal tibia fracture (B, C). Given intact neurologic status, multiple attempts were made at limb salvage to include arthrodesis (D). This was complicated by infection (E) and treated to solid fusion using biplaner external fixation (F-H). At 8.8 months after injury, she was unsatisfied with her function and decided to undergo transfemoral amputation (I).

The selected level of amputation was the next most proximal level away from the primary source of dysfunction. Anatomic location of the initial injury was as follows: 8 distal tibia/hindfoot, 6 leg, 4 knee, 1 thigh, 1 midfoot, 1 forearm, and 1 hand. Of the 14 patients with transtibial amputations, ideal tibial length was easily obtained in 9 patients with midfoot, hindfoot, or distal tibia injuries with a native proximal tibia allowing for an appropriate tibial resection level. Although we expected a decrease in final outcome with transtibial amputations through the initial zone of injury, there was no significant difference in visual analog score (VAS) or subjective functional status.

A majority of patients (16 of 22 [72.7%]) reported multiple indications for late amputations, with an average of 2.1 specific indications per patient. Non-neurogenic pain was the most common report in 12 of 22 patients, followed by 8 nerve dysfunction, 8 poor function, 7 infection, 5 neurogenic pain, 4 fracture nonunion or malunion, and 2 soft tissue breakdown. Unless diagnostic sympathectomy was performed, we separated neurogenic and non-neurogenic pain by patient-described pain characteristics, with descriptions of burning pain and hypersensitivity supporting neurogenic/neuropathic pain. Although the mechanism of dysfunction was complicated in all patients, each patient was able to select the primary indication for amputation with 6 selecting neurologic dysfunction, 6 persistent or recurrent infection, 3 neurogenic pain, 5 non-neurogenic pain, and 2 overall poor functional results (Table 2).

Table 2: Patients Undergoing Late Amputation
Click image to view larger table. (PDF)

Ultimately, with an average of 15 months (range, 2-36 months; median, 12 months) clinical follow-up, all patients were satisfied with their decision for amputation and would undergo amputation again if given the choice. Unfortunately, as is common with this population, 7 patients required repeat procedures for heterotopic ossification (4) or postoperative infection (3). At the most recent follow-up, the average VAS was an acceptable 1.75 (range, 0-5; median, 2). All patients reported subjectively improved function, with many back to preinjury activities such as swimming and running.

Discussion

Significant attention has been given in the civilian orthopedic trauma literature to the complexities of limb salvage vs amputation following major extremity trauma. Numerous scoring systems—including the Hannover Fracture Scale-9710; Limb Salvage Index11; Mangled Extremity Severity Score12; Nerve Injury, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient13; and Predictive Salvage Index14—have been developed in an effort to predict successful limb salvage and assist surgeons in determining when early amputation should be performed in an acute civilian trauma setting. Unfortunately, while the specificities are frequently adequate to predict successful limb salvage, the sensitivities of these scores have been found inadequate in predicting amputation in both retrospective and prospective studies by other investigators.15-18 Furthermore, the status of plantar sensation at presentation is frequently included as a critical factor in determining acute limb salvage vs amputation; however, follow-up of Lower Extremity Assessment Project subgroups failed to demonstrate a correlation between absent initial plantar sensation and amputation, functional outcomes, or even the presence of normal plantar sensation at 2 years.19

We did not attempt to apply these scoring systems in the present series. In addition to the inherent limitations and potential futility of extremity injury scoring suggested above, limited data were available regarding the apparent status of the extremity in theater at the time of injury, and none of these systems have been developed for or evaluated in a chronic/delayed setting such as that in which our elective amputations were performed. We found that persistent sensory/motor nerve dysfunction, independent of and separate from neurogenic or non-neurogenic pain status, was the most frequently cited primary and overall indication for amputation.

Some authors have suggested that improved results may be achieved with early amputation in a posttraumatic setting,20 but the Lower Extremity Assessment Project study did not reflect a clear benefit in both short- and long-term functional outcomes with regard to limb salvage vs amputation.8,9 Numerous authors have reported the short- and long-term outcomes of primary traumatic and early amputees from previous military conflicts,21-25 but comparative groups of limb salvage and amputation patients are largely lacking outside of prior small series (from 1 of our institutions early in the present conflicts), which did not include functional outcome data.26,27 As mentioned, relatively little is known about the incidence of, risk factors for, and results of late amputations in combat-related, or even civilian trauma-related, severe extremity injuries. The Lower Extremity Assessment Project study reported a late amputation rate of 3.9% in the limb salvage group, with ranges from 2.1% to 9.1% depending on the level and type of injury.8 A comparative assessment of amputation levels and timing from that series found no differences between amputation immediately, during the initial hospitalization, or within 3 months of injury.28

All amputations in the present series were performed >4 months postinjury. While it is conceivable that the aggressive efforts at limb salvage undertaken for our patients prior to amputation assisted them in their decision process and eventual acceptance of (or resignation to) amputation, rehabilitation was likely delayed in many cases by this prolonged treatment course. The quantitative impact of delayed amputations on functional outcomes in the present series is difficult to assess due to associated injuries and the absence of a suitable control group. Outcomes from within our study cohort would be putatively biased due, as a rule, to the poor preamputation extremity-specific function.

One additional risk factor for late amputation that is difficult to quantify is the prolonged treatment course and peer interactions at the institutions involved. Walter Reed Army Medical Center and Brooke Army Medical Center have both been formally designated as Amputee Patient Care Centers by the US Army Amputee Patient Care Program. Using a sports medicine-based rehabilitation model, multidisciplinary teams of specialists in amputee care were developed to maximize patient surgical and rehabilitative outcomes. Similar amputee centers were created during prior conflicts ranging from World War I to the Vietnam War and have proven use toward these ends.22 Naturally, the result has also been the congregation of large numbers of amputees, forming a valuable peer support group present throughout the convalescence and rehabilitation process. We feel that this, in turn, has resulted in greater perceived social acceptance of amputation and amputees, in addition to the frequent and visible onsite demonstrations of amputee performance and function. It is therefore likely that some, if not most, of our delayed amputees were influenced in their decisions by their frequent interactions with other amputees.

The existing military and civilian literature regarding trauma-related amputations is strongly biased toward the lower extremity and largely neglects upper-extremity amputations. Although somewhat less frequent, upper-extremity amputations are often more functionally and cosmetically devastating.27,29 Our study was not exclusive to the lower extremity and did include 2 elective, late transradial amputations. Twenty of the 22 late amputations were in the lower extremity, however, with transtibial amputations being by far the most common (14 amputations). We believe this is due to the relative frequency of injury patterns in the distal lower extremity, particularly for severe hindfoot injuries and distal tibia fractures, as well as the generally good function that transtibial amputations afford. In contrast, the Lower Extremity Assessment Project study authors found worse Sickness Impact Profile scores in their transtibial amputations than their transfemoral amputations as a whole, although the difference was not statistically significant.8,28 In support of the functionality (both real and perceived) of more distal amputations, however, it is noteworthy that we have performed no elective late amputations at the transhumeral, shoulder disarticulation, or hip disarticulation levels.

To our knowledge there is no preexisting literature regarding the outcomes of elective amputation for chronic pain or poor limb function in a military, posttraumatic setting. Of some concern is the potentially high incidence of phantom pain in amputees, which historically ranges from as low as 4% to as high as 88%.23-25,30

Similarly variable results have been reported regarding treatment and persistence of phantom pain, which must be distinguished clinically and diagnostically from phantom sensation or localized stump pain. Reports of phantom pain range from reliable relief from or disappearance of symptoms following treatment in most patients25,30 to lasting effective benefits in only 1%.23,24 Further, patients undergoing elective amputation for persistent pain may experience persistence or recurrence of symptoms.31-33

In contrast, Honkamp et al34 reviewed 18 of 20 patients undergoing transtibial amputation for chronic foot and/or ankle pain refractory to nonoperative management, excluding those due to diabetes and peripheral vascular disease. They reported clinically and statistically significantly (P<.0001) decreased pain intensity and frequency at an average follow-up of 41 months. Seventeen of their 18 patients discontinued (10) or decreased (7) their narcotic use, and 16 patients reported they would undergo the procedure again. One patient was unsure, and only 1 patient of 18 reported they would not have an amputation again. While all the patients in their study underwent delayed amputation for pain, only 8 of our patients had the primary report of pain (neurogenic or non-neurogenic) in deciding for delayed amputation. In the present series, all patients reported they would undergo the elective, delayed amputation again if given the option to do so.

The present study was retrospective in nature and is subject to all limitations and biases affecting retrospective series. This was also not a comparative series; that is, we did not study a control group of limb salvage patients with appropriately severe injuries who had not gone on to elective late amputation. However, the number of late, elective amputees is a relatively small component (approximately 5%) of our total amputees to date, and an even smaller proportion of the total number of inpatients treated for combat-related extremity injuries. Rather, we have performed an analysis of risk factors and subjective patient outcomes following elective, delayed amputation for combat-related extremity trauma.

All patients with persistent or recurrent infection did not have life- or limb-threatening infections, and those with persistent nonunions or malunions of fractures were similarly not beyond continued limb salvage using commonplace, modern orthopedic techniques. Functional outcomes beyond subjective patient perceptions were not assessed; this was complicated by our relatively short follow-up, additional associated injuries, and the variable levels of elective amputation involved. Our institutions, along with additional major military medical centers, are in the process of performing a large, prospective study of limb salvage and amputation in this patient population.

Conclusion

While every reasonable effort is given to limb salvage following combat-related extremity trauma when medically and functionally practicable, a small number of patients have persistent symptoms or poor function to such a degree that elective, delayed amputation is requested. From our results, there is no single risk factor that increases the likelihood of delayed amputation, but the combination of complex pain symptoms with neurologic dysfunction appears to increase the risk, particularly if the initial insult is a severe hindfoot injury or distal tibia fracture. With appropriately selected and counseled patients, elective late amputation results in a high degree of patient satisfaction and subjectively improved function.

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Authors

Drs Helgeson, Potter, and Gajewski are from the Orthopedic Surgery Service, Department of Orthopedics and Rehabilitation, Walter Reed Army Medical Center, Washington, District of Columbia; Dr Burns is from the Orthopedic Surgery Service, Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, Texas; and Dr Hayda is from Brown University Warren Alpert School of Medicine, Rhode Island Hospital, Providence, Rhode Island.

Drs Helgeson, Potter, Burns, Hayda, and Gajewski have no relevant financial relationships to disclose.

The views expressed herein are those of the authors and should not be construed as official policy of the Department of the Army, Department of Defense, or US government.

Correspondence should be addressed to: MAJ Benjamin K. Potter, MD, Walter Reed Army Medical Center, Orthopedic Surgery Service, 6900 Georgia Ave NW, Bldg 2, Clinic 5A, Washington, DC 20307 (Benjamin.Potter@amedd.army.mil).

doi: 10.3928/01477447-20100722-02

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